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PubMed2006

Analysis of cardiovascular disease and kidney outcomes in multidisciplinary chronic kidney disease clinics: complex disease requires complex care models.

PURPOSE OF REVIEW: Chronic kidney disease is recognized as being highly prevalent in the population, and associated with morbidity and mortality relative to the general population. The complexity of patients and the multiplicity of interventions required to maintain health has forced clinicians to develop different models of healthcare delivery. This publication reviews the current literature on specific interventions to reduce progression of chronic kidney disease and cardiovascular disease, and studies the examination of outcomes of patients exposed to different healthcare delivery models. Specifically we examine the rationale and outcomes of those seen in multidisciplinary clinics. RECENT FINDINGS: Current evidence supports the use of rennin-angiotensin system blockers, reduction of blood pressure and proteinuria and phosphate control. Additional less robust studies support the need for attention to anemia, hyperparathryoidism, and other more "kidney specific" risk factors. The attendance of identified chronic kidney disease patients at multidisciplinary clinics appears to improve survival once dialysis is started. Despite aggressive management, not all patients are able to meet clinical targets associated with improved outcomes. SUMMARY: The recognition of the complexity of chronic kidney disease care and the need to develop and test models of care in addition to the single interventions is a challenge for both researchers and clinicians. Current data support the use of multidisciplinary clinics in improving outcomes of referred patients. Future research will help to refine and define appropriate care models for this growing chronic kidney disease population.

Calcium↗

PubMed2006

The complex relationship between dependency and domestic violence: converging psychological factors and social forces.

Research indicates that economic dependency in women and emotional dependency in men independently contribute to domestic-partner abuse risk and that high levels of emotional dependency in an abused partner may reduce the likelihood that the victimized person will terminate the relationship. An analysis of psychological factors and social forces that contribute to domestic violence suggests that multimodal intervention strategies are needed to combat this complex problem.

Codependency, Psychological↗

PubMedDate not supplied

The role of the nurse on a transdisciplinary early intervention assessment team.

Assessing young children with disabilities is a complex process requiring the expertise of a team of professionals from several disciplines. Team members often include the child's family members, early childhood special educators, clinical psychologists, speech-language pathologists, social workers, physical and occupational therapists, pediatricians, and nurses. A team approach meets standards of best practice in early childhood intervention and encourages full family participation in the assessment process. This article explores the process of team building, role release through a transdisciplinary approach, and a nurse's role on a transdisciplinary assessment team.

Child↗

PubMed2006

Complex sleep apnea syndrome: is it a unique clinical syndrome?

STUDY OBJECTIVES: Some patients with apparent obstructive sleep apnea hypopnea syndrome (OSAHS) have elimination of obstructive events but emergence of problematic central apneas or Cheyne-Stokes breathing pattern. Patients with this sleep-disordered breathing problem, which for the sake of study we call the "complex sleep apnea syndrome," are not well characterized. We sought to determine the prevalence of complex sleep apnea syndrome and hypothesized that the clinical characteristics of patients with complex sleep apnea syndrome would more nearly resemble those of patients with central sleep apnea syndrome (CSA) than with those of patients with OSAHS. DESIGN: Retrospective review SETTING: Sleep disorders center. PATIENTS OR PARTICIPANTS: Two hundred twenty-three adults consecutively referred over 1 month plus 20 consecutive patients diagnosed with CSA. INTERVENTIONS: NA. MEASUREMENTS AND RESULTS: Prevalence of complex sleep apnea syndrome, OSAHS, and CSA in the 1-month sample was 15%, 84%, and 0.4%, respectively. Patients with complex sleep apnea syndrome differed in gender from patients with OSAHS (81% vs 60% men, p < .05) but were otherwise similar in sleep and cardiovascular history. Patients with complex sleep apnea syndrome had fewer maintenance-insomnia complaints (32% vs 79%; p < .05) than patients with CSA but were otherwise not significantly different clinically. Diagnostic apnea-hypopnea index for patients with complex sleep apnea syndrome, OSAHS, and CSA was 32.3 +/- 26.8, 20.6 +/- 23.7, and 38.3 +/- 36.2, respectively (p = .005). Continuous positive airway pressure suppressed obstructive breathing, but residual apnea-hypopnea index, mostly from central apneas, remained high in patients with complex sleep apnea syndrome and CSA (21.7 +/- 18.6 in complex sleep apnea syndrome, 32.9 +/- 30.8 in CSA vs 2.14 +/- 3.14 in OSAHS; p < .001). CONCLUSIONS: Patients with complex sleep apnea syndrome are mostly similar to those with OSAHS until one applies continuous positive airway pressure. They are left with very disrupted breathing and sleep on continuous positive airway pressure. Clinical risk factors don't predict the emergence of complex sleep apnea syndrome, and best treatment is not known.

Adult↗

PubMed2004

Meiosis I arrest and azoospermia in an infertile male explained by failure of formation of a component of the synaptonemal complex.

OBJECTIVE: To characterize the early stages of meiosis in a male with unexplained azoospermia. DESIGN: Case report. SETTING: Case Western Reserve University and University Hospitals of Cleveland. PATIENT(S): A 30-year-old male with nonobstructive azoospermia. INTERVENTION(S): Immunostaining for components of the synaptonemal complex and recombination-associated proteins, fluorescence in situ hybridization (FISH) for specific chromosomes. MAIN OUTCOME MEASURE(S): Progression to and through pachytene of meiosis I in controls and in the patient. RESULT(S): We observed complete meiosis I arrest in the patient, associated with failure of formation of the mature, tripartite synaptonemal complex. CONCLUSION(S): Abnormalities in synaptonemal complex formation are responsible for a proportion of cases of unexplained male infertility.

Adult↗

PubMed2005

[Mitral valve repair of valve insuffficiency with broad and complex lesions due to infective endocarditis; report of a case].

Surgical intervention is necessary for the treatment of infective endocarditis, although antibiotic therapy has been shown to be effective for treatment of this disorder. Mitral valve infective endocarditis frequently presents with broad and complex lesions, and thus a variety of valve repair is needed. A 40-year-old woman with mitral valve insufficiency due to infective endocarditis underwent mitral valve repair. During the operation, torn chordae, aneurysm with perforation of the anterior leaflet, and torn chordae of the posterior leaflet were found. The chordae of the anterior leaflet were reconstructed and the aneurysm was excised, and autopericardial patch repair was performed. Then, resection and suturing of the prolapsing lesion of posterior leaflet were performed. Mitral valve repair preserves the left ventricular apparatus and function. Therefore, mitral repair results in better prognosis than valve replacement. The repair of the mitral valve should be attempted for the treatment of valve insufficiency due to infective endocarditis.

Adult↗

PubMed2004

Why don't stage-based activity promotion interventions work?

Despite the well-described benefits of regular physical activity, around 70% of adults in the UK fail to meet current activity recommendations. Interventions based on the Transtheoretical, or Stages of Change, Model of behaviour change have been proposed as one potentially effective method of promoting physical activity levels. However, two recent reviews have found little evidence that individualized stage-based activity promotion interventions are any more effective than control conditions in promoting long-term adherence to increased levels of physical activity. Possible reasons for this are: that exercise behaviour is a more complex group of behaviours than currently recognized; that many algorithms for determining current stage of activity change have not been validated; that exercise behaviour is determined by a number of factors not addressed by stage-based interventions; that the stages of change model encourages focus on stage progression which is not always associated with behaviour change; and that truly stage-based interventions are highly complex requiring more than one level of development and evaluation--a challenge that has not yet been met. Thus, stage-based activity promotion interventions may simplify exercise behaviour beyond what is useful for practitioners and health promoters. Paradoxically, stage-based activity promotion interventions that have been developed to date may have failed to appreciate the true complexity of the task.

Attitude to Health↗

PubMed2005

Changes in the slope of the first major deflection of the ECG complex during acute coronary occlusion.

To evaluate the effect of acute coronary occlusion (ACO) during percutaneous coronary intervention (PCI) on the slope of the first major deflection of the QRS complex (the initial QRS slope). Standard ECG signals of 18 patients (89 leads), undergoing PCI were recorded prior to and during ACO. The initial QRS slope was calculated in the baseline state and during ACO. Changes in the standard ECG were detected in 36 of 89 leads (40%). The initial QRS slope during ACO was significantly different from baseline in 74 of 89 leads (83%). The specificity of the change in the slope during ACO was low (29%).

Angioplasty, Balloon, Coronary↗

PubMed2005

Social competence in children with language impairment: making connections.

Children with language problems frequently experience social difficulty. This is the case not only for children diagnosed as having impairments such as autism spectrum disorder, Asperger syndrome (AS), or mental retardation but also for children falling into diagnostic categories traditionally considered to be primarily language based (e.g., language impairment, learning disability). In considering what interventions might be most effective, it is important to consider how various aspects of development are connected. This article describes causal networks in which various factors influence the relationship between language deficits and social difficulties. Case descriptions of Joseph, an adolescent with language impairment, and Cari, a 6-year-old diagnosed with AS, illustrate the complexity of this relationship and demonstrate how intervention might be designed to facilitate positive social communication outcomes.

Affect↗

PubMed2003

Emerging drugs for renal failure.

Renal failure involves a significant impairment of the essential functions of the kidney, which can be either acute with sudden and rapid onset (acute renal failure [ARF]) or chronic with gradual onset (chronic renal failure [CRF]). ARF, if detected early, may be halted or reversed, whereas CRF is generally irreversible. Without treatment or intervention, both forms of renal failure lead to end stage renal failure (ESRF) or end stage renal disease (ESRD), requiring renal replacement therapy (RRT) in the form of dialysis or renal transplantation for survival. However, provision of RRT requires expert teams working in specialised units, making therapy of patients with renal failure expensive; furthermore, RRT is complex, with its own complications. Although pharmacological interventions have shown promise in experimental models, these have not been as successful in the clinical setting (e.g., administration of atrial natriuretic peptide, low-dose dopamine). At present, drugs are administered during CRF to either reduce one of the many risk factors of CRF (e.g., angiotensin-converting enzyme inhibitors, statins) or to deal with the consequences of CRF (e.g., erythropoietin, calcitriol). Recent evidence suggests that some of these interventions may provide further direct beneficial effects via reduction of renal inflammation. Although these interventions have greatly improved the prospects for patients suffering ESRF, the development of novel drugs and therapies with which to reduce the consequences of renal failure and ESRD remain topics of great interest. This article reviews the therapies available for the prevention and management of renal failure in adults and describes, in detail, emerging drugs and novel interventions that may soon become available for the treatment or prevention of ESRF.

Acute Kidney Injury↗

PubMed2006

A framework for improving health in cities: a discussion paper.

This paper considers health in cities from the perspective of complex adaptive systems. This approach has a number of important implications for intervention that do not emerge in traditional accounts of cities and health. The paper reviews various accounts of the nature of cities and of health as well as the traditional urban health and Healthy Cities movements. It then provides a framework for intervention and tests it against an actual case study. It concludes that a complex adaptive systems framework opens up fresh possibilities for improving health in urban contexts.

Attitude to Health↗

PubMedDate not supplied

Fall prevention in frail elderly nursing home residents: a challenge to case management: part I.

Parts I and II of this article examine the impact of a falls prevention program on the fall incidents among the residents in a nursing home. It was hypothesized that a diagnostic, therapeutic, and preventive approach should be used for nursing home residents identified as being at high risk for falls in order to reduce the number of fall incidents and to improve quality of life for this vulnerable population. The program effectively targeted both intrinsic and extrinsic factors to reduce risks facing the residents. The effectiveness of the program was evaluated by examining changes in the rate of falls after the program was implemented. The results identified that a multifaceted program, one that utilized multiple personalized interventions, was effective in reducing the falls rate of frail (those with complex medical and psychosocial problems) nursing home residents, and that muscle-strengthening interventions may be beneficial for this vulnerable population. Program outcomes verified that case managers can impact quality of life for frail elderly nursing home residents by promoting their independence and safety, and postponing problems resulting from inactivity. Part I discusses the background and process of a falls program and factors contributing to the occurrence of falls. Part II will examine the interdisciplinary team approach to assessment, method, and implementing strategies for an effective fall prevention program. Tools used for prevention, monitoring, and investigation of falls will be detailed in Part II.

Accident Prevention↗

PubMedDate not supplied

Fall prevention in frail elderly nursing home residents: a challenge to case management: part II.

Parts I and II of this article examine the impact of a falls prevention program on the fall incidents among the residents in a nursing home. It was hypothesized that a diagnostic, therapeutic, and preventive approach should be used for nursing home residents identified as being at high risk for falls in order to reduce the number of fall incidents and to improve quality of life for this vulnerable population. The program effectively targeted both intrinsic and extrinsic factors to reduce risks facing the residents. The effectiveness of the program was evaluated by examining changes in the rate of falls after the program was implemented. The results identified that a multifaceted program, one that utilized multiple personalized interventions, was effective in reducing the falls rate of frail (those with complex medical and psychosocial problems) nursing home residents, and that muscle-strengthening interventions may be beneficial for this vulnerable population. Program outcomes verified that case managers can impact quality of life for frail elderly nursing home residents by promoting their independence and safety, and postponing problems resulting from inactivity. Part I (LCM, Nov-Dec 2001) discussed the background and process of a falls program and factors contributing to the occurrence of falls. This month we examine the interdisciplinary team approach to assessment, method, and implementing strategies for an effective fall prevention program. Tools used for prevention, monitoring, and investigation of falls are also detailed.

Accident Prevention↗

PubMed2003

Modeling tissue-specific signaling and organ function in three dimensions.

In order to translate the findings from basic cellular research into clinical applications, cell-based models need to recapitulate both the 3D organization and multicellular complexity of an organ but at the same time accommodate systematic experimental intervention. Here we describe a hierarchy of tractable 3D models that range in complexity from organotypic 3D cultures (both monotypic and multicellular) to animal-based recombinations in vivo. Implementation of these physiologically relevant models, illustrated here in the context of human epithelial tissues, has enabled the study of intrinsic cell regulation pathways and also has provided compelling evidence for the role of the stromal compartment in directing epithelial cell function and dysfunction. Furthermore the experimental accessibility afforded by these tissue-specific 3D models has implications for the design and development of cancer therapies.

Animals↗

PubMed1997

Treatment algorithms in child psychopharmacology research.

Clinical trials in child psychiatry research have increased in complexity. Several factors have contributed to this change, including the need to compare multiple therapies, to re-create clinically relevant situations in research, to standardize treatment approaches, to account for the impact of comorbidity, to respond to the needs of individual patients, and to optimize treatment accordingly. To preserve the clinical and internal validity of the experimental interventions vis-à-vis their increasing complexity, researchers have started developing treatment algorithms. These deductive systems for handling data allow us to standardize and incorporate clinical judgment into study designs through the adoption of a stepwise decision making process. Treatment algorithms are different from treatment guidelines. Guidelines are general recommendations that apply to groups of patients with certain characteristics; they are not fully detailed and are created with the expectation that clinical judgment will be applied in individual cases. Algorithms are patient specific, are intended to capture all the relevant details of the clinical situation, and require minimal clinical judgment for their clinical application; they are designed to minimize the role of clinical judgment in research protocols. The entire multistep algorithm is tested in a clinical trial, not the single steps that constitute the algorithm, so proving the efficacy of an algorithm cannot replace a controlled assessment of the individual treatments embedded in the algorithm. Some characteristics, properties, and limitations of algorithms in child psychiatry and psychopharmacology research are presented along with two examples of algorithms currently used in child and adolescent psychopharmacology. Although treatment algorithms seldom have been used in pediatric psychiatry and psychopharmacology, there are indications that their use will increase in the near future and will allow the standardized introduction of clinical judgment into research design.

Adolescent↗

PubMed1999

Lipid-lowering therapy in membranous nephropathy.

Membranous nephropathy (MN) is a very common cause of nephrotic syndrome in adults, and lipid abnormalities are, therefore, frequently found in these subjects. Although efficient lipid-lowering therapy is available, almost nothing is known about the contribution of hyperlipidemia in the pathogenesis of progressive renal failure in MN. Studies in an experimental animal model of human MN, Heymann nephritis, have shown that lipids play an essential role in the pathogenesis of proteinuria. Local production of reactive oxygen species after subepithelial immune complex deposition leads to the formation of lipid peroxidation (LPO) adducts, which ultimately alter the composition of the glomerular basement membrane. As the magnitude of urinary protein excretion is associated with the long-term prognosis, a normalization of glomerular permselective properties has been used as a surrogate parameter for the beneficial effects of treatment. Probucol, a drug with LPO inhibitor potential, is able to reduce urinary protein excretion in rats with passive Heymann nephritis. In humans with MN, preliminary data also support this observation. It remains to be determined, however, if this intervention, which does not interfere with immune complex formation, will reduce the number of the patients reaching end-stage renal failure because of MN. In conclusion, lipids may contribute to glomerular injury in MN, as LPO might be an especially important factor, opening the possibility for new therapeutic interventions, thereby avoiding the side-effects of the currently used treatment regimen.

Glomerulonephritis, Membranous↗

PubMed2005

Research-design issues in cancer-symptom-management trials using complementary and alternative medicine: lessons from the National Cancer Institute Community Clinical Oncology Program experience.

PURPOSE: To identify major research-design issues in proposals submitted by investigators in the Community Clinical Oncology Program (CCOP) for clinical trials of complementary and alternative medicine (CAM) for cancer-symptom management. METHODS: We conducted content analysis of all scientific reviews of concepts and protocols submitted by the CCOP to the National Cancer Institute (NCI) to identify research challenges in conducting clinical trials designed to evaluate CAM interventions for cancer-symptom management. RESULTS: Since the inception of the NCI Office of Cancer Complementary and Alternative Medicine in 1998, a total of 46 symptom-management studies using CAM interventions have been proposed by CCOP investigators, with 20 studies now in progress comprising 22% of the current total CCOP symptom-management portfolio. Proposals fell into four categories: complex natural products; nutritional therapeutics; mind-body interventions; and alternative medical systems. The most significant research-design issues arose as a consequence of the lack of preclinical data for CAM interventions and the lack of quality-control standards comparable with those used in regulating new pharmaceutical agents. CONCLUSION: Across the different types of CAM interventions, the most common problems found in proposed research designs are related to unwarranted assumptions about the consistency and standardization of CAM interventions, the need for data-based justifications for the study hypotheses, and the need to implement appropriate quality control and monitoring procedures during the course of the trial. To advance the state of the science, future research must address these critical issues if CAM interventions are to be evaluated rigorously and have a consequent impact on clinical practice and general public awareness.

Cancer Care Facilities↗

PubMedDate not supplied

[Management of malnutrition in preschool children: the role of primary health care services].

Although the prevalence of malnutrition in developing countries is decreasing, it is still a major problem for many children under five. As socio-economic conditions are the main determinants, a final solution for this problem can only be envisaged in the long run. Still, short-term strategies need to be defined in order to relieve the sufferings of individual children and their families. Understanding the problem and consequently formulating intervention programs at the local level remains a complex and difficult issue. The first reason being that the process of malnutrition expresses itself in different forms and with variable consequences. A second reason making malnutrition a complex problem is that the primary causes -- the interaction between insufficient food supply and the frequent recurrence of infectious diseases -- are determined by a multitude of factors of different natures. This complexity -- of its expressions, effects, and causality -- makes it difficult to get a global vision and understanding of the problem, which clearly impedes the definition of rational and integrated intervention strategies. Nevertheless, a better understanding of the pathophysiology of malnutrition and of the factors that influence the growth process in preschool age, will help to better direct actions. To this effect, a conceptual model will be built, based on recent insight in the process of malnutrition within this age group. From this model, two lines of action for increasing the chances of preschool children to express their initial growth potential, become apparent. A first series of activities could tackle the process that, via wasting and recurrence of infections, leads to an increased mortality risk. As timely intervention reduces the risk of depletion of energy reserves, these activities would also have an indirect impact on physical development. Elaborating strategies for secondary prevention and for treating severe cases belongs to the specific competence of the health sector. In the second line of action, the aim is to intervene before reserves are depleted. Here, primary prevention and health promotion are choice activities. This frame of reference will be used for analysing existing health programs for preschool children and how they propose to improve the management of malnutrition. This analysis will show that primary health care services can play a much more important role than usually attributed to them. Identifying these gaps and elaborating alternatives is the purpose of this article.

Child Development↗